A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.
The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.
Redness, swelling, and warmth of the affected area.
Pain level rated as 8/10 on a numerical scale C.
Wound culture results pending.
Risk for infection related to impaired skin integrity.
Applied moist heat compresses to the wound site.
Correct Answer : A,B
These are the only options that describe the subjective and objective data of the patient, which are part of the SOAP documentation method. SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.
Choice C is wrong because wound culture results are not part of the assessment entry in SOAP documentation. They are part of the investigation results, which are usually documented in the objective section.
Choice D is wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment. Nursing diagnoses are usually documented in the plan section of SOAP documentation.
Choice E is wrong because applied moist heat compresses to the wound site is an intervention, not an assessment. Interventions are also documented in the plan section of SOAP documentation.
Normal ranges for vital signs are as follows:.
• Blood pressure: 90/60 mmHg to 120/80 mmHg.
• Pulse rate: 60 to 100 beats per minute.
• Respiratory rate: 12 to 20 breaths per minute.
• SpO2: 95% to 100%.
• Temperature: 36.5°C to 37.5°C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
To provide continuity of care.
A care plan conference is a meeting between the nursing home staff, the resident, and the resident’s family to set measurable, specific goals for the resident to meet during their stay, decide what needs to be done to meet those goals, and decide who in the nursing home is responsible for performing each job necessary to help the resident.The main purpose of this meeting is to provide continuity of care, which means ensuring that the resident receives consistent and coordinated care across different settings and providers.
Choice A is wrong becauseto discuss possible solutions to certain client problemsis not the main purpose of a care plan conference, although it may be one of the topics discussed.
A care plan conference is not meant to address only specific problems, but rather the overall plan of care for the resident.
Choice B is wrong becauseto evaluate the effectiveness of the care givenis not the main purpose of a care plan conference, although it may be one of the outcomes of the meeting.
A care plan conference is not meant to assess only the performance of the staff, but rather the progress of the resident.
Choice C is wrong becauseto gather information for the plan of careis not the main purpose of a care plan conference, although it may be one of the steps involved.
A care plan conference is not meant to collect only information, but rather to use it to develop and update the plan of care.
Correct Answer is B
Explanation
It allows access to client information from multiple locations.
This is an advantage of using a computerized system for documentation and reporting because it enables health care providers to access relevant and updated information about their clients from different locations, such as hospitals, clinics, or home care settings.This can improve the quality and continuity of care, as well as facilitate communication and collaboration among different members of the health care team.
Choice A is wrong because it is not true that a computerized system eliminates errors and inaccuracies in documentation.While a computerized system can reduce some types of errors, such as illegible handwriting or misplaced files, it can also introduce new types of errors, such as data entry mistakes, software glitches, or system failures.
Choice C is wrong because it is not true that a computerized system reduces the need for verbal or written communication among health care providers.On the contrary, a computerized system can enhance communication by allowing health care providers to share information more easily and quickly, but it does not replace the need for verbal or written communication to clarify, confirm, or discuss the information.
Choice D is wrong because it is not true that a computerized system protects client information from unauthorized disclosure or alteration.
While a computerized system can provide some security features, such as passwords, encryption, or audit trails, it can also pose some risks, such as hacking, phishing, or malware attacks.Therefore, health care providers need to follow ethical and legal guidelines to ensure the confidentiality and integrity of client information in a computerized system.
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